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PTSD and Other Invisible Wounds affecting our
Service Members and Veterans
1
Alan Peterson, PhD, ABPP
Alan Peterson, PhD, ABPP• Retired USAF Lt Col Clinical Health Psychologist
• Former Chair, Department of Psychology at Wilford Hall
• Deployed in support of Operations Noble Eagle, Enduring
Freedom, and Iraqi Freedom
• Professor and Chief of Division of Behavioral Medicine at
University of Texas Health Science Center at San Antonio
• Research Health Scientist, San Antonio VA
2
• Professor, University of Texas at
San Antonio
• Director, STRONG STAR
Consortium, Consortium to
Alleviate PTSD, and National
Center for Warrior Resiliency
Signature Injuries of OEF/OIF/OND
• Amputations
• Burns
• Posttraumatic Stress Disorder (PTSD)
• Traumatic Brain Injury (TBI)
How Common is PTSD?
• Affects 7% of Americans
• 4% adult males
• 10% adult females
• Percentage is twice as high in military service members and veterans (14%)
0
2
4
6
8
10
12
14
16
PTSD Prevalence
Males
Females
GeneralPopulation
ServiceMembers &Veterans
Prevalence of Trauma and PTSD in the US
60.7
51.2
8.1
20.4
91.9
79.6
0
10
20
30
40
50
60
70
80
90
100
Men Women
Percen
t (%
)
Trauma
PTSD
Kessler (1995)
Rate of PTSD is Influenced
by the Type of Trauma
Kessler (1995)
0
10
20
30
40
50
60
Disaster Accident Assault Molestation Combat* Rape
Per
cen
t (%
)
Trauma PTSD
Rate of PTSD is Influenced
by the Type of Trauma
0
10
20
30
40
50
60
70
80
90
No Rape Rape
- Threat, - Injury
- Threat, + Injury
+ Threat, - Injury
+ Threat, + Injury
Kilpatrick et al., (1989)
Percentage of Crime Victim Groups With and Without Rape, Life Threat, and Physical Injury
that Developed Crime-Related PTSD
Who is at Greatest Risk for PTSD?
• Those with most significant or
frequent traumas
• Tip-of-the spear military warriors
• Those in blast explosions
resulting in horrific and mutilating
injuries and death
• Those who experience significant risk of personal injury or
death
• Those who experience things no humans should have to
experience
PTSD, PTS(D), or PTS?
• Former Army Vice Chief of Staff Gen Chiarelli
opposed the term “disorder”
• Suggested calling it posttraumatic stress (PTS)
• Others have suggested using the terms:• Combat stress injury
• Combat and operational stress reaction
• Currently accepted term is PTSD• Important to differentiate PTSD from PTS
• Perhaps most important point is that civilian research
has shown PTSD can be treated into remission and in
most cases there is no relapse
Postdeployment PTSD & PTS
in Ft Hood Soldiers
• N = 1416 Soldiers evaluated postdeployment
• PTSD diagnosis using PCL-M plus DSM-IV-TR algorithm
52%
26%22%
0%
10%
20%
30%
40%
50%
60%
No PTS PTS PTSD
Postdeployment PTSD & PTS
in Ft Hood Soldiers
• N = 1416 Soldiers evaluated postdeployment
• PTSD diagnosis using PCL-M plus DSM-IV-TR algorithm
52%
26%22%
0%
10%
20%
30%
40%
50%
60%
No PTS PTS PTSD
PTS(D)?
Comorbidities of PTSD
• PTSD has many related or comorbid conditions
• Depression
• Sleep Disorders
• Chronic Pain
• Traumatic Brain Injury
• Substance Use Disorders
• Suicide
Need for Military-Relevant
PTSD Research
• U.S. facing potential national health crisis
• Current need for treatment may exceed capacity
• Few studies to guide treatment of PTSD in military
• Medical discharge for post-9/11 veteran for PTSD:
• $500K estimated cost for lifetime disability
• Imperative not to repeat Vietnam scenario
What is the most common
myth about PTSD?
What is the most common
myth about PTSD?
PTSD is a chronic, lifelong
condition that is very
difficult to treat
Institute of Medicine (2008)
• The committee concludes that the current scientific
evidence for the treatment of PTSD is:
• Sufficient to conclude the efficacy of exposure
therapies
• Inadequate to determine the efficacy of EMDR,
cognitive restructuring, coping skills training, and group
format psychotherapy
• Inadequate to determine the efficacy of PTSD
treatment with pharmacotherapy
Evidence-based Treatment of PTSD in
Civilian Populations
Prolonged Exposure (PE): (Edna Foa, PhD)Involves repeated exposure to:
• Memories of the trauma• Trauma-related situations
Cognitive Processing Therapy (CPT): (Patricia Resick, PhD)
Reduces PTSD symptoms through:• Writing/reading accounts of the trauma• Challenging/modifying trauma-related cognitions
Loss of PTSD Diagnosis in Civilians after Treatment with PE and CPT
0
20
40
60
80
100
Pretreatment 5-Year Follow-Up
Perc
en
t w
ith
PT
SD
Cognitive Processing Therapy (n = 63)
Prolonged Exposure (n = 64)
Resick et al., 2012
Unanswered Questions
• What treatments are most effective for combat- or
deployment-related PTSD in active duty military?
• How must civilian treatments be tailored for military
populations?
• What percentage of service members can remain on
active duty and deploy again after treatment?
• What is the impact of redeployment/re-exposure to
combat trauma after treatment for PTSD?
Unanswered Questions
• What is the impact of comorbid conditions on the
treatment of PTSD and
• TBI
• Insomnia
• Substance Use Disorders
• Chronic Pain
• Suicide Risk
Unanswered Questions
• How does the brain change after effective treatment
for PTSD?
• Are there genetic factors that determine who
develops combat-related PTSD?
• Can PTSD be prevented by using prophylactic
medications?
• What factors are related to risk and resiliency?
www.STRONGSTAR.org
Open treatment studies at:
www.STRONGSTAR.org/treatment
STRONG STAR: South Texas Research Organizational
Network Guiding Studies on Trauma And Resilience
CAP: Consortium to Alleviate PTSD
• Headquartered at UT Health San Antonio
• World’s leading research consortia for diagnosis, prevention &
treatment of combat PTSD and related conditions (sleep
disorders, chronic pain, suicide, TBI, substance use disorders)
• 40 collaborating universities, hospitals, & institutions
• 52 peer-reviewed funded research projects
• 28 active research projects
• 140 collaborating investigators and clinicians
• Over $150 million in peer-reviewed research funding
26
STRONG STAR-CAP
•Vision: To reduce or eliminate combat-
related PTSD in active-duty military and
recently discharged veterans
•Mission: To support multi-disciplinary &
multi-institutional research collaboration with
the synergy to develop new PTSD
prevention & treatment programs that could
not be achieved independently 27
Brief Summary of STRONG STAR Findings
• Resick (2015), Group CPT vs Group PCT for PTSD• PTSD can be effectively treated with group CPT
• Rudd (2015), Brief CBT for Suicide• Suicide attempts reduced by 60%
• Resick (2016), Individual vs Group CPT for PTSD• Individual CPT is more effective than Group CPT
• Taylor (2017), CBTi for insomnia• In-Person CBTi more effective than Web-Based CBTi
• Cigrang (2017), Brief PE in Primary Care• Brief treatment by behavioral consultants is effective
• Foa (2018), Massed vs Spaced PE for PTSD• Both are effective for combat-related PTSD
28
TBI
Traumatic Brain Injury (TBI)
• A traumatically induced structural injury and/or a
physiologic disruption of brain function
• as a result of an external force
• that is indicated by new onset or worsening of
• at least 1 of 5 clinical signs immediately
following the event
VA/DOD Definition of TBI
• At least one of the following clinical signs
immediately following the event:
• Loss of consciousness
• Loss of memory for events immediately before
or after injury
• Alteration in mental state at the time of injury
• Neurologic deficits
• Intracranial lesion
How is TBI Diagnosed?
• Interview
• Physical Examination
• Neurobehavioral Symptom Inventory
• Notes:
• TBI is a historical event
• It is most often retrospectively diagnosed
Severity Classification of TBI
Criteria Mild Moderate Severe
LOC 0 - 30 mins 31 mins - 24 hrs >24 hours
AOC Moment - 24 hrs >24 hours. Severity based on
other criteria
PTA 0 - 1 Day 2 – 7 Days >7 Days
GCS 13 - 15 9 – 12 <9
Structural
Imaging
Normal Normal or
Abnormal
Normal or
Abnormal
How is TBI Treated?
• Mild TBI (concussion)
• Over 30 randomized clinical trials have been
conducted
• No evidence-based treatments have been
identified
• Primary approaches:
• Rest and inactivity
• Clinical Symptom Management
TBI Diagnostic Challenges
• Diagnostic criteria are based largely on patient
self-report, particularly for mild TBI
• Possible threats to diagnostic accuracy:
• Recall bias
• Cognitive difficulties
• Overlap of symptoms in co-morbid conditions
• Other factors
TBI and PTSD Symptom Overlap
TBI• Insomnia
• Memory Problems
• Poor concentration
• Depression
• Anxiety
• Irritability
• Headache
• Dizziness
• Fatigue
• Noise/light intolerance
PTSD• Insomnia
• Memory problems
• Poor concentration
• Depression
• Anxiety
• Irritability
• Re-experiencing
• Avoidance
• Emotional numbing
In Summary
Signature Injuries of OIF/OEF/OND
PTSD
TBI
Burns
Amputations
THE Signature Injury of
OIF/OEF/OND
Blast Trauma
The Salute Seen Around
the World(1:36)
Contact
Alan L. Peterson, PhD
University of Texas Health Science Center at San
Antonio
Office Phone: (210) 562-6700
Cell Phone: (210) 508-5428
Email: [email protected]
